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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> "A'la rk W A�v.5' , ' <br /> d ❑ Zoning Status; CUP; <br /> OWNER ADD SS (Number,Street,City,State,Zip) '" / <br /> ©4 k u)c7d4ve 0 �i°rivh j4 1 $ c3,C-- y Deed Variance Restriction; CSM <br /> HOME HONNEE� CELL PHONE JJ/ E-MAIL ADDRESS L VarlBnCe(# ) <br /> 6o(IN -30 61 (0O K ,9O&93 7 Vii►( 'ri c� ,0d&X ,o� �Q �,.J Site Plan drawn to scale <br /> AGENT INFORMATION 1 CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> /T7/flc/elieX.f`f4 .I ❑ Site Plan including location <br /> AGENT ADDRESS CO ACTOR ADDRESS 5. 3 Y ' of well/septic <br /> , ,,' a ��4' + 7 Afl <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> 40 f aro 61'3 7 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> r 'I(cvp�bJ�t-torr -,4'i t/ CQ, or plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of <br /> PARENT PARCEL N BER: CURRENT ZONING: ACREAGE: property <br /> ❑ PARCEL 0 Q a/ <br /> 57 02 -. 367 ,2 (p y 2 , / frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> /Q J�j,'o w '/a: 141/4: <br /> Driveway permits <br /> ADDRESS: (state,county,town) <br /> /01 (3&k- oai GiAl, &o/s o.i W S 35-351 ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> tiwoo <br /> 3 2 3 3 (-/ S o' 3 (public,private) <br /> 4 <br /> f <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> D ec4 ❑ Zoning District <br /> ❑This project is a new building or structure. ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address ..' <br /> ❑SEWER ❑SEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetiand/FlooVain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> ❑ ErosionConttolpermit <br /> BASEMENT: 1ST FLOOR: Z <br /> 4 TOTAL SQUARE FOOTAGE: j (s s,di rb nce,' <br /> ♦ filling/access) <br /> 2ND FLOOR: 3RD FLOOR: S Z a <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) $ , `l, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? CJ Yes ❑No Li Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 0 No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes ®No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 6 No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes ®No ❑Don't know - <br /> {` <br /> 7. Is this to correct a violation? ❑Yes ErNo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) -► -► -∎ <br />